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Acute-on-chronic liver failure severity determines short-term mortality

Researchers found that while acute-on-chronic liver failure prevalence decreased over a 10-year period, overall survival of patients with grade 3 acute-on-chronic liver failure did not improve, according to data published in Journal of Hepatology.

“Studies show that the number of organ failures — used to define the stage of disease — is the strongest predictor of short-term mortality in ACLF,” Ruben Hernaez, MD, MPH, PhD, from the Michael E. DeBakey Veterans Affairs Medical Center in Texas, and colleagues wrote. “Other factors, including patient demographics, etiology of cirrhosis, and type of precipitating factors have been variably implicated in impacting outcomes in ACLF.”

Hernaez and colleagues identified 72,316 patients admitted for more than 24 hours with an episode of decompensated cirrhosis between 2004 and 2014. Of those included in the study, 26.4% met the criteria for ACLF, including grade 1 (12.8%), grade 2 (10.1%) and grade 3 (3.5%).

Mortality at 28 days was higher in patients with ACLF compared with those without ACLF (25.5% vs. 10.4%; P < .01) and the risk for 28-day mortality increased with grade severity from 16.87% in grade 1 to 53.3% in grade 3. At 90 days, 40% of patients with ACLF died compared with 21.3% of those without ACLF.

Among patients with ACLF, 28-day mortality increased significantly in those with two organ failures (OR = 1.89; 95% CI, 1.74-2.05) and those with three or more organ failures (OR = 4.5; 95% CI, 4.04-5.01).

Other factors associated with a higher risk for mortality included increasing age (aOR = 1.03; 95% CI, 1.02-1.03), presence of hepatocellular carcinoma (aOR = 1.7; 95% CI, 1.5-1.92), and higher MELD-Na score (aOR = 1.05 per unit increase; 95% CI, 1.04-1.06).

Overall ACLF prevalence decreased from 27% in 2004 to 22.17% in 2014. The prevalence of ACLF grade 1 and grade 3 remained stable, whereas grade 2 decreased from 11.1% in 2004 to 7.4% in 2014. Mortality at 28 days decreased among patients with ACLF grade 1 and grade 2 during the 10-year period, but the researchers observed no significant temporal change in 28-day or 90-day transplant-free mortality among those with grade 3.

“Given the dismal outcomes of patients with ACLF grade 3, it is important that clinicians recognize this syndrome as a different entity, not as ‘mere decompensation,’ and start liver transplant evaluation, which, at the Veterans Affairs should trigger a referral to the National Surgery Office to improve transplant outcomes at the VA,” Hernaez and colleagues wrote. – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.